HomeMy WebLinkAbout15-210f r t
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52 240-1 82 6
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
IDENTIFICATION NO. �5-- a ] C _
(Office Use Only)
APPLICATION FOR TAXICAB I MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
l allure to eo Hole&e Elle "reoulreri" iniortna€bon will result in de tiff of the arxtvfloatlan
First
Middle
2 Address (REQUIRED) Y)ey of rt,l6j c:,-+
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3. Contact Information (RE,QUI ED} Email ,MuQJ� 2o�[J j/g)7op 'C0 Cell Phone:
M 0 2r - (All written communication sent via email)
ua6 (�? Yo 11 00 Q 1
4a. Chauffeur's License expiration date (REQUIRED) 1 l 212— v IS
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of pe
_ I
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Al
Type of offense
Where
When
What happened to the charge? (Circle one) ,f/V
Convicted Dismissed Deferred Suspended Plead Guilty Other V -O
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense
Where A1/A When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) NO
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
0212015
APPLICATION FOR TAXICAB VE14ICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transportation a v lid Chauffeur's license number
15 2 [} D `� 5 3 5 issued on 4(2311 ( expiring on 9 )201 /S . I understand that if I
falsely answer any questions in this application, that this application may be denied. I agree that in making this application, I
consent to allow agents or employees of the City of Iowa City, Iowa, in their discretion, to examine any and all records and
documents relating to this application, and I further agree that, if authorization to be a taxicab driver is granted, to comply at all
times with all of the provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant &A,6' — � Date L 15
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by �1 c� &c, on this day of
�� iOls
,a� r WENDY S, MAYER Notary Public in 6Ihd for the State o5 owa
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that
there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of Chauffe 'g license
Sign lure of Police hief or des ate
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
Signature City Clerk or designee
Datb
ClerklrAXIDRNBADGEAPPL92014amentled DOC 03/2015
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Office Use Only
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Approved applications
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DCI report
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State certified driving record
Website update
ClerklrAXIDRNBADGEAPPL92014amentled DOC 03/2015
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May. 8.
2015
2:52PM
Div
of
Criminal
Investigation
No 6804 P.
9/17
Flo rn aaw
m rown uuy
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os/os/:o16 11103 *066
P.002/0o2
0111 STAllE OF ROVJA
Crrf nP'nal@ ff�Wmy Lkecozrd Check k
To:Iowa ]]ivfsigl of Criminal Ir)v_esel�ajioo
21S r. 9'" Street
Des Moines, Iowa 50319
(515) 725-6066
(51) 735.6080 rax
:. r . r:.; al u: u , M rh.�le n,s
DCl Accouni Numbm L- EDUr%'�"
(Ir applicable)
Froltlt City ofll?Wa 0)'--
410 E. washlneton Street
Iowa City, I.4 52240
Phone: 319-356-5041
rax: 319-356-5491
Last Name (maodswy)
First Name (merldalory)
Afdlddle Name (rcconmlmded)
� J�V1 s
K0 k& \,r _
Date of Birth (mandatory)
Gender (niandno )
Social S/peeuri i�A[f1lJ B1p(recaremeod tl)
MIale ❑ Female
Waiver Information., Without a signed waiver from the subject of the request, a complete criminal history record may not
he releasable, per Code of Iowa, Chapter 692.2. For com lete criminal history record information, os nhov ed by lavr, ahvays
obtain a walvor si nature from the subject of the reQuest.
Waiver Release; l hereby givc permission for the above requesting official to conduct an lour cmninal bislory record check*illi rhe Division of Criminal
Inresligalivn (l)Cl). Any criminal history data cenarning nm Ihat is mainlaiu:d by II¢ DC[ mar be rcln5ed as allowed by law.'
WaiverSignafure;_
Iowa Criminal History Record Check Results (DClUse el,lY)
As of _ _ s5 S , a search of the provided name and date of biltll revealed: - en
- wl
No Iowa Criminal History Record found with DO
® Iowa. Criminal history Record attached, DCl d
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DCT initials--k--
DCI-77
t
DCI.77 (08/25/10)
Received Time May. 6. 2015 10 57AM No. 7224